Job Title: Children’s Quality Reviewer(s)
Division and/or Department: Managed Health & Long Terms Care Services
Prepared by: JK
Date of initial version: 8/17/2016
Date most recently reviewed, updated, etc.: 1/24/2017
Pay type: ☒Salaried or ☐Hourly
Preferred FTE: ☒Full time; ☐75-80%; ☐50%; ☐Other:
Job is budgeted as ☒Regular; ☐Limited term; ☐Other:
In collaboration with the Bureau of Children’s Services, this position will work to develop and conduct review activities to ensure compliance with federal and state requirements for children served under the Children’s Long Term Care support waivers in Wisconsin. The waivers support children who are living at home or in the community and who have substantial limitations in multiple daily activities as a result of one or more of the following disabilities: developmental disabilities, severe emotional disturbances, and physical disabilities.
The position will interact with county agencies serving the children during the activities conducted to ensure compliance, remediation, and provide technical assistance. Applicants interested in applying for this position should have experience with children who have developmental disabilities, severe emotional disturbances, or who have physical disabilities. Experience could be from a variety of settings, such as educational, clinical, residential, community or recreational groups, or vocational
Reports to: one of two Project Managers, MHLTC
Other individuals or MetaStar sections with whom the person interacts with:
MHLTC Department staff
Information Technology Department staff
Wisconsin Department of Health Services (DHS) staff, primarily:
Division of Long Term Care
Division of Health Care Access and Accountability
Managed Care Organization (MCO) staff
County Health and Human Services staff and affiliated sub-contractors operating the WI Children’s Long Term Support Waivers program
Include, Respect, I Self direct (IRIS) Consultant Agencies and Fiscal Employment Agent staff
Family Care (FC), Family Care Partnership (FCP), and Program for the All Inclusive Care of the Elderly (PACE) members and authorized representatives
IRIS Participants and authorized representatives
Outline of key responsibilities of this position:
Conduct external quality review activities for Children’s Long Term Support Waiver, FC/PACE/FCP, Badger Care Plus, SSI, IRIS and programs as directed by DHS.
External quality review is the analysis and evaluation of aggregated information on quality, timeliness, and access to services furnished by these programs and is conducted according to protocols published by the Center for Medicare and Medicaid Services.
Review activities include but are not limited to those described below. Starred activities are conducted according to CMS protocol:
Coordination and Continuity of Care review activities (record reviews)
Access multiple electronic health record systems and read member/participant records to evaluate compliance with certain federal and state requirements as well as industry standards. Priorities are placed on confirming that member/participant health and safety is assured. Effectively communicate results orally and in writing.
Compliance with Federal and State standards for Medicaid managed care programs*
Understand and apply federal and state requirements. Read and analyze documentation submitted by an MCO. Facilitate discussions with a wide variety of staff to determine and evaluate the effectiveness of implementation of expectations throughout an MCO. Determine level of compliance and effectively communicate results orally and in writing.
Validation of Performance Improvement Projects (PIPs)*
Read and analyze written reports regarding improvement of clinical and non-clinical processes or outcomes of care, associated documentation, and data from MCOs. Facilitate discussions to confirm understanding. Determine if the project was designed, conducted, and reported in a methodologically sound manner. Effectively communicate results orally and in writing.
Read written proposals from MCOs designed to achieve improvements of clinical or non-clinical processes or outcomes of care. Provide technical assistance orally and in writing and make recommendations about approval status.
Validation of Performance Measures*
Conduct reviews according to review protocols to abstract and verify performance measurement data from a variety of sources, but not limited to medical records, encounter data, MCO and DHS systems data.
Collaborate with MCO and agency representatives to obtain missing and clarify existing data.
Summarize and compile findings using standardized forms and templates for reports.
Review and mediation activities associated with FC, FCP, PACE, IRIS and Children’s Long Term Care waiver program member appeals and grievances.
Triage and talk with members, participants, and/or legal representatives to identify and understand concerns. Access multiple electronic health record systems and read member/participant records. Communicate with all parties via telephone and work to mediate a resolution. Document all activities in a database and communicate outcomes in writing.
Develops and implements review activities independently and in collaboration with others in MHLTC and including DHS staff. Review activities must align with CMS protocols, as needed.
Creates review activity and aggregate reports according to timelines and formats developed in collaboration with DHS.
Participate in inter-rater reliability testing in order to achieve standards of accuracy and consistency in applying review guidelines for specific review activities.
Review the work of others and work collaboratively with team members through ongoing feedback to ensure that work meets internal and external quality standards.
Collaborates with MHLTC team members to improve existing systems/processes/standard operating procedures (SOPs) and to develop new ones.
Some day and overnight travel is required; travel dates are scheduled in advance. All other duties as assigned.
CORE ORGANIZATIONAL COMPETENCIES:
Teamwork: Demonstrates respect and achieves cooperative relationships in fulfilling the vision and mission of MetaStar.
Communication: Demonstrates good interpersonal skills with all whom they interact. All communications, verbal and written, should demonstrate a commitment to internal and external customer service and excellence. Effectively sends, receives, and responds to requests while maintaining a high level of confidentiality.
Initiative: Committed to and performs quality work contributing to the vision and mission of MetaStar. He/she assumes responsibility and accountability for his/her actions. Meets the challenges of a changing environment, is timely in meeting job responsibilities, and strives to provide excellent customer service. Values accomplishments and shows enthusiasm and pride in the organization. He/she demonstrates a self-directed work effort. Develops goals for professional growth and strives to achieve those goals.
Customer Service: Demonstrates a commitment to courteous, sincere, and sensitive customer service. He/she presents a positive and caring attitude in all interactions. He/she is patient, tolerant, accepts diversity, and presents a positive image of themselves and MetaStar in all professional interactions.
Quality Improvement: Demonstrates a commitment to quality and excellence. He/she solves problems through critical evaluation of data-based information and application of continuous quality improvement methods. Can accurately identify and diagnose issues, identify alternatives, implement a plan, and evaluate and communicate results.
QUALIFICATIONS, REQUIREMENTS, ETC.
Bachelor’s Degree in Special Education, Nursing or health or human services-related field will be considered (social work, rehabilitation psychology, mental health, substance abuse services, or other allied health professions).
For Registered Nurses, years of experience as noted below may be considered as a substitute for Bachelor’s Degree in Nursing. Licensure/certification in the State of Wisconsin, as appropriate.
Minimum of 5years experience preferred (3 years’ experience considered) in direct practice in working with specific target populations, based on the current needs of the MHLTC department including, but not limited to; developmentally disabled, and/or physically disabled children; and children with severe emotional, behavioral, mental health and substance use disorders.
Experience in coordination of acute and primary and/or long-term care services, consumer education related to disease management, education and coordination of services for children and families of children with developmental and/or physical disabilities and severe emotional disturbances.
Long term experience preferred, including knowledge of managed care delivery systems, organizations and financing.
Knowledge of continuous quality improvement, process improvement and Lean principles.
Experience in performance measurement, quality assessment, and quality improvement projects or initiatives including:
Application of sound and effective information gathering, analysis and decision making strategies
Assessment of the significance of information with regard to standards and regulations
Production of clear, focused and professional written documentation.
Knowledge of the conditions, current philosophies, nationally recognized approaches and community alternatives for the adult and children’s populations being served under the managed health and long-term care waiver programs, Knowledge of Medicaid eligibility and benefit policies, data systems and processes.
Knowledge and proficiency in using electronic medical and health records systems.
Proficiency in Microsoft Office applications.
Ability to work well independently and within a team structure.
Self-motivated, critical thinker with a strong desire to learn and apply existing and new skills.
Excellent communication (oral and written) and small and large group facilitation skills.
Valid Wisconsin Driver’s License
Interest and availability for in-state and overnight travel
TO APPLY SEND RESUME & COVER TO:
mail to: MetaStar, c/o HR, 2909 Landmark Place, Madison, WI 53713
MetaStar, Inc., is an equal opportunity employer.